1. Conscience in the Clinic: When Patient Requests and Physician Ethics Conflict Matthew A. Allison, MD, MPH Assistant Professor Family and Preventive Medicine

2. Ethical Theories

3. Normative Ethical Theory A principle that can be used to decide what morally ought to be done and the rationale supporting it A principle that can be used to decide what morally ought to be done and the rationale supporting it Bayes M and Henley K. Right Conduct: Theories and Applications. 1983. Random House, New York.

4. Egoism One always ought to promote one’s own interest, as the only rational basis for deciding what to do. One always ought to promote one’s own interest, as the only rational basis for deciding what to do. Without considering the interests and values of other people Without considering the interests and values of other people

5. Subjectivism Moral judgements are simply expressions of personal preferences Moral judgements are simply expressions of personal preferences “matter of opinion” “matter of opinion”

6. Skepticism Moral judgements can never be known to be true Moral judgements can never be known to be true That is, there simply is no such thing as knowing that an action is right or wrong That is, there simply is no such thing as knowing that an action is right or wrong

7. Relativism The validity of moral judgements are relative to some authority The validity of moral judgements are relative to some authority For example, society is the absolute moral authority For example, society is the absolute moral authority

8. Utilitarianism Morality depends solely on the consequences (ends obtained) of the conduct Morality depends solely on the consequences (ends obtained) of the conduct

9. Natural Law The rightness of an action is determined by reference to nature rather than to convention, custom or preferences The rightness of an action is determined by reference to nature rather than to convention, custom or preferences In this case, nature = human nature guided by rational thought In this case, nature = human nature guided by rational thought

10. Ethical Decision Making

11. Rights vs. Responsibilities

12. Rights A valid claim or entitlement that a person can make to restrict the conduct of others in their dealings with him/her A valid claim or entitlement that a person can make to restrict the conduct of others in their dealings with him/her If there are no other conflicting moral obligations, it is obligatory to respect and individual’s rights If there are no other conflicting moral obligations, it is obligatory to respect and individual’s rights

13. Rights Types Types Positive Positive Directly providing assistance for the holder of the rights Directly providing assistance for the holder of the rights Negative Negative Not interferring with the rights of the holder Not interferring with the rights of the holder

14. Responsibility The sense in which one is responsible for achieving (or maintaining) a good result in some matter. The sense in which one is responsible for achieving (or maintaining) a good result in some matter. “Obligations” “Obligations”

15. Case

16. Case You are the resident physician in an OB/GYN clinic seeing patients for urgent care services. The current case is a 17 year-old female accompanied by her mother. The patient presents with dysmenorrhea during her last period. Specifically, she had very little menses and associated lower abdominal cramping. This was 2 months ago. You ask additional historical questions and then state that you would like to do a physical examination. She asks that this examination be done without her mother present. You are the resident physician in an OB/GYN clinic seeing patients for urgent care services. The current case is a 17 year-old female accompanied by her mother. The patient presents with dysmenorrhea during her last period. Specifically, she had very little menses and associated lower abdominal cramping. This was 2 months ago. You ask additional historical questions and then state that you would like to do a physical examination. She asks that this examination be done without her mother present.

17. Case (cont) As you begin the examination, the patient states that she did a pregnancy test two weeks ago, which was positive. She communicates that this is the result of a "one-night stand" and that she does not want to approach the man who fathered the child. She also does not want her parents to know about this and therefore asks for an abortion to be performed. She insists that this procedure be kept strictly confidential (even to the point of not telling your attending physician). As you begin the examination, the patient states that she did a pregnancy test two weeks ago, which was positive. She communicates that this is the result of a "one-night stand" and that she does not want to approach the man who fathered the child. She also does not want her parents to know about this and therefore asks for an abortion to be performed. She insists that this procedure be kept strictly confidential (even to the point of not telling your attending physician).

18. Case (cont) Of note, you have been certified to complete abortion procedures independently. Although you are not an overly religious person, it is your ethical belief that performing some abortions is unacceptable. Of note, you have been certified to complete abortion procedures independently. Although you are not an overly religious person, it is your ethical belief that performing some abortions is unacceptable.

19. Question #1 Are you ethically or legally obligated to inform the patient's mother of her daughter's pregnancy? Are you ethically or legally obligated to inform the patient's mother of her daughter's pregnancy?

20. Question #2 Must you consult with your attending physician (against the patient's wishes)? Must you consult with your attending physician (against the patient's wishes)? What do hospital rules and professional ethics require here? What do hospital rules and professional ethics require here? What do you tell the patient? What do you tell the patient?

21. Question #3 If a physician believes abortion in these circumstances would be morally wrong, what are his or her legal and professional obligations? If a physician believes abortion in these circumstances would be morally wrong, what are his or her legal and professional obligations? Are you legally or professionally bound to refer the patient to another physician for abortion services? Are you legally or professionally bound to refer the patient to another physician for abortion services?

22. Question #4 How in this situation and others like it can you best reconcile personal ethical principles and the welfare of your patient? How in this situation and others like it can you best reconcile personal ethical principles and the welfare of your patient?